87254A - Lane, Kimberly

❑CAMA [IDREDGE & FILL N9 87254 n`)B cn,�/
Previous permit s V
3 GENERAL PERMIT Date previous permit issued
.=
9❑v New ❑Modification ❑Complete Reissue ❑Partial Reissue
As authorized by the State of North Carolina, Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursuant to:
I SA NCAC ❑ Rules attached. ❑� General Permit Rules available at the following link: www.de .nc. ov CAMArules
Applicant Name
City
Phone # ( )
Email
State
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s)
Subdivision
City
Affected ❑ CW ❑ EW ❑ PTA F-1] ES ❑ pTS Adj. Wtr. Body (nattman/unk)
AEC(s): ❑ OEA ❑ IHA ❑ UW ❑ SPIMA ❑ PWS Closest Maj. Wtr. Body
ORW: yes/ho PNA: yes/no
Type of Project/ Activity
(Scale: j
Access Length !
-
-_..
_[T1
1'""'
Pier(dock)lengthT-[F-F'T]-
_
--
Fixed Platform(s) ':•� -
;
i
_.-
—.
Floating Platform(s)
__
-
-
tc
Via,[
[(tK
F�--
Finger pier(s)
Total Platform area
Groin length/# F
—I
T
Bulkhead/Riprap length
Avg distance offshore
Breakwater/Sill
Max distance/length
Basin, channel
A
—
;
_Zr
�
S_.
-
- —
—
—
--
—
---
Cubic yards-X
Boat ramp
h--SP
C
Boathouse/ Boatlift
) .._
y
!
_
is
!!l 4
)
�
_
I
Beach Bulldozing
—�
(
'•
-
Other
!
1^-
--
—
I
1
_
_
-
SAV observed: yes
--
Moratorium: n/a yes no
Site Photos: yes no
Riparian Waiver Attached: -yes no
A building permit/zoning permit may be required by:
Permit Conditions
`, ifs,{,I--'k:`
❑ TAR/PAM/NEUSE/BUFFER (circle one)
❑ See note on back regarding River Basin rules
❑ See additional notes/conditions on back
I AM AWARE OF STATUTES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANCE STATEMENT. (Please Initial)
Agent or Applicant PRINTED Name Permit Officer's PRINTED Name
Signature **Please read compliance statement on back of permit** Signature
Application Feels) Check #/Money Order Issuing Date Expiration Date

DIVISION OF COASTAL MANAGEMENT
�z
do hereby authorize
ov6mer of the property located at:
q'.—gs,�.r zvrp=�. aching as agent)
to act as my agent for the purpose of obtaining am1y needed Coastal Area Management Act and/or
Dredge and Pill Act permits, that may be new frr t2le proposed development at the above -
indicated property, which entails:
�I.s<e1t
(describe proposed deveiopment for whit h permits are being sought)
This agency authorization is limited to the specific activities described above, and will expire on:
(date on which agency authorization expires)
(date)
(title, if officer of core• owner or trustee far property)

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER N QSF,I ATrIONAIDAIV VFORM
(Too potion to be comp',eted by owner or their agent)
Name of •'aoerty OWrie' L I
A 2?a
.'NA. n tr. c r f(ik� c. k c
Address of Property:
Vlaiil"a Ad�reSS 0? OWner: i �Y�._ �qq Jr��tO-7ni
d�f1.'J- . r.er's P^cre=: � F� /
I .Agent ?'^onek:�----�--�—�-
Agents Name: KjCV `—=—a�-�-GL r
Acen S Email.
AD ACENT RirAR A ?ROctZTy 0),.VN -..R'S CERTIFICATION
;Bottom ortior. to be cam leted'o ' the Adjacent Pro a Owner'
p = c �c croperty The individual aoclying for this
er=by ce"fY'hai i ow^ crape y ad zce ,a vs ; e
ca ., .,'ras described is ,ie. ass v
[ne a ed '' a i� :he deveiopr•era they are araoosing A tleSCr'�i.=" �r
_ , 0O have abjections to this proposal.
J F ! CC LCT ".eve objectians cc ;hs proFcsa:
ou have objections to what Is being proposed: you :^rust nottP/ the N.C. Division of Coastal
Pzrag=_.mar-c LCr�j in r+rf:ng Yfltht" 5JJ days o' recel�rof fh:s notice. Carraspondanca should be
rafted to 401 S. Griffin, St; Sie. 30G, Elizabeth ;cf ed r 7q sai DCM reprasantatives can also be
co.^.tacted at ,252j 254.3901. No rasper:sa ;s=b^s:darad "r^ same as no objection. if you have Deer.
notlffed by Certified ,Mal"
WAPIEF SEC -ION
- � s. soa`. ra-ro breakwater. boathouse. lift, arMe
�ndersiar.d thy: ery proposed Pier. door. Tc "g =��='y a-aa c. -:,,avian access uniess waived by
Sa .,ems
-.is` :^e set beak a m'n,mu -.. , . �^ ..w;;n �`c "Na�ve t^e setback. You must Sian
a_.
_ cces r.ct zpPiy to bu'ichaads c. .. ...
_rw . mate Mark Oelow
eial' a' `.'^e ' aaoack lJf
CO ws". ``-c waive so,m-
y;acer:.R aran?racer`/Owi^er
do net wis ::a we,
?'n_
se oaak a -:e
ga.a_.re cf Adjacent Riparian Procery v,v-:ar
r•
ypedlPrinted name of ARPO:"'r�i"`
;klai!ing Address a' ARPO: ✓
d<�:rn„iz4 1.C'I.C"""RFD's
qZ?C's em r v , ra vaa, ", ^^. AR°C's Signature"
a wa .,a is Va :d
Date: < N a V d V Revised `,rcay 2021
�y

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
CERTIFIED MAIL RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner: -
AddressofProperty: Im�r`E--
Mailing Address of Owner: 1 uq (1('/o
Owner's emaili'�i111%2--��
Agent's Name: I? t_ _T 4 ka h=�a� L
-1Rsy
Phone#: ,f �tU- Sd� -to 70 %
Agent Phoned: �)i) 3 - C' �) L-1 .
Agent's Email:
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adjacent Properly Owner)
I hereby certify that I own property adjacent to the above referenced property. The individual applying for this
permit has described to me, as shown on the attached drawing, the development they are proposing. A
. r rtrnwinn with dimensions, must be provided with this letter.
I DO NOT have objections to this proposal. 1 DO have objections to this proposal.
if you have objecfions to what is being proposed, you must notify the N.C. Division of Coastel
Management (DCM) in writing within 10 days of receipt of this notice. Correspondence should be
mailed to 401 S. Griffin St., Ste. 300, Elizabeth City, NC, 27909, DCM representatives can also be
contacted at [phone]. No response is considered the same as no objection if you have been
notified by Certified Mail.
WAIVER SECTION
I understand that any proposed pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or
groin must be set back a minimum distance of 15' from my area of riparian access unless waived by me
(this does not apply to bulkheads or riprap revetments). (If you wish to waive the setback, you must sialn
the appropriate blank below.)
I DO wish to waive somefall of the 15' setback 111A
Signature of Adjacent Riparian Property Owner
-OR-
I do not wish to waive the 15' setback requirement (initial the blank) XJ I
Signature of Adjacent Riparian Property Owner: . firk
TypediPrinted name of ARPO: -n� l -I I} rc'T U �'n T0 il,
Mailing Address of ARPO: r W ff t� —1 Mf^y (� C. k
r1Vl A+L,<vm - C-7 GVIG
ARPO's email: i t i sTcraLr �VV ARPO's Phone#: 7 i% 3 i
Date- 2.- 2 _ 2-0-L't *waiver is valid for up to one year from ARPO's Signature*
Revised July 2021

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5' by 75' DOCK

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